reimbu r sement gu di e f o r wireless video capsule e n … is the indication for wireless capsule...
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ReimbuRsement Guide foR
Wireless Video Capsule endoscopy pRoceduRes
Important Notice to Readers: This document is intended to help physicians, hospitals, and ambulatory surgery centers better understand Medicare reimbursement (coding, coverage, and payment) for select wireless capsule endoscopy procedures that involve Olympus Endo Capsule and associated Olympus capsule endoscopy equipment.
The Mdicare payment amounts are based on published values and national average payment amounts; actual payment will vary for each provider based on site of service and geographic location, among other things. The presence of a code or billing a particular code is not a guar-antee that a provider will receive payment.
Payment, coding, and coverage policies vary from insurer to insurer and are updated frequently, so the policies and payment rates change over time (usually annually). The chart included in this document summarizes the CPT code descriptors. Providers should check the complete AMA CPT reference manual and/or another authoritative source for the full descriptor and a complete listing of all CPT codes. It is the provider’s responsibility to report the code(s) that accurately describes the procedures furnished and the patient’s diagnosis. Providers should review applicable Medicare or other insurer’s guidelines and instructions to ensure that billing practices comply with the insurer’s requirements; providers should contact Medicare or the insurer if they have any questions.
The information provided in this guide does not constitute legal advice and is not a substitute for legal advice. Providers must consult with competent legal counsel regarding legal matters. Under no circumstances shall Olympus or its employees, consultants, agents, or representatives be liable for any costs, expenses, losses, claims, liabilities, or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this guide or any use thereof.
© 2009 Olympus America Inc.
What is it?Wireless Capsule Endoscopy is a non-invasive, diagnostic imaging system that uses a disposable, miniature, video digital camera contained in a non-biodegradable capsule. The capsule is swallowed to allow painless observation of the entire small bowel mucosa. 1
How does it work?The diagnostic imaging system is comprised of three components:
➤ Ingestible Capsule containing a miniature, color video camera, a light source, batteries, a miniature radio transmitter, and an antenna. The capsule is propelled by peristalsis and can provide more than 5 hours of images, cross-referenced with localization data
➤ Data Recorder, carried on the belt, receives and stores signals transmitted by the capsule. This allows users to continue about their daily activities during the examination.
➤ A computer workstation is needed to perform image and data processing, creating a video that may be viewed by the physician offline.1
What are the Medicare indications for coverage, scope of coverage and/or medical necessity for the use of wireless capsule endoscopy?
The scope of Medicare coverage for wireless capsule endoscopy may vary from contractor to contractor. Providers should contact the Medicare contractorintheirjurisdictionformorespecificinformationandfollowtheir contractor’s guidelines and billing instructions. Please see the Claim Processing section in this guide for more CMS Local Coverage Determination (LCD) information.
Wireless Capsule endoscopy
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What is the indication for wireless capsule endoscopy?Capsule endoscopy is used for visualization of the small bowel mucosa.
What are the Medicare documentation requirements for reimbursement of wireless capsule endoscopy?
The medical record must be available upon request and should include:
➤ Documents to support medical necessity.
➤ ICD-9-CM diagnosis codes.
➤ Narrative notes documenting need for the test.
➤ Reports of previous negative upper and lower endoscopies performed during the current spell of illness.
➤ Documents indicating presence of gastrointestinal bleeding and anemia secondary to blood loss.
➤ Documents supporting that service was rendered to completion.
➤ Review of the images and physician interpretation (report).1
private payersAlwayscheckwithyourpayerforpayercontract-specific requirements, indications for coverage, scope of coverage, medical necessity and/or documentation requirements for the use of wireless capsule endoscopy.
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CpT Codes
CpT Codes
What CpT code is used to bill for wireless capsule endoscopy for small bowel?
The CPT code for wireless capsule endoscopy for small bowel is as follows:
91110 Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy) esophagus through ileum, with physician interpretation and report.2
ModiFiers
What are modifiers? Modifiersindicatethataservicewasalteredinsomewaybyaspecificcircumstance that differs from the stated description without actually changingthebasicdefinitionoftheservice.2
What are modifiers TC and 26 that are assigned when coding for capsule endoscopy?
Modifier TC stands for Technical Component. The Technical Component charges are institutional charges.3
Modifier 26 stands for the professional Component. The Professional Component is the physician’s portion of the procedure.2
CpT C
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es
Medicare Claim processingThere are two Medicare billing forms for reimbursement. The CMS 1450 form, also known as UB-04, which is the institutional claim form, and the CMS 1500 form, also known as 08/05, which is the professional claim form.
FormsCMs 1500 (08/05): Medicare Claims processing Manual
http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf
CMs 1450 (uB-04): Medicare Claims processing Manual
http://www.cms.hhs.gov/manuals/downloads/clm104c25.pdf
place of service Codes
electronic data interchange and electronic Billingdetails on the Medicare electronic data interchange (edi) and electronic Billing
http://www.cms.hhs.gov/ElectronicBillingEDITrans/
MediCare ClaiM proCessiNG
11 Office
22 Outpatient Hospital
ClaiM proCessiNG
Advanced Beneficiary Notice (ABN)Effective March 3, 2008, providers (including independent laboratories), physicians, practitioners, and suppliers may use the revised ABN (Form CMS-R-131) for all situations where Medicare payment is expected to be denied. The revised ABN replaces the ABN-G (Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB (Form CMS-2007). Beginning March 1, 2009, the ABN-G and ABN-L will no longer be accepted. As required by Section 1879 of the Social Security Act, the ABNisusedtoinformbeneficiariesofpotentialfinancialliability,exceptinhomehealthcare and inpatient hospital settings.
The revised ABN CMS-R-131 form and instructions can be found at the CMS website below:
http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp#TopOfPage
CMs local Coverage determination (lCd) sitesThe LCD website includes the following convenient pages:
➤ Alphabetical listings for LCDs by contractor, state, and LDC type:
http://www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp#TopOfPage
➤Searchable data for LCDs for wireless capsule endoscopy by geographic area, keyword, CPT/HCPCS code, ICD 9 code, coverage topic, or date criteria:
http://www.cms.hhs.gov/mcd/search.asp?clickon=search&
Cla
iM pr
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essiNG
What is the CpT code for small bowel wireless capsule endoscopy?91110 Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy) esophagus through ileum, with physician interpretation and report.
Are modifiers used with the CPT code for small bowel wireless capsule endoscopy?
Insomeinstancesmodifiersareused: 91110 – TC Gastrointestinal tract imaging, intraluminal (e.g. capsule endoscopy) esophagus through ileum, with physician interpretation and report — Technical Component.
91110 – 26 Gastrointestinal tract imaging, intraluminal (e.g. capsule endoscopy) esophagus through ileum, with physician interpretation and report — Professional Component.
FreQueNTlY asKed QuesTioNs
FaQ
What forms should i use for the wireless capsule endoscopy claim process?There are two CMS billing forms for reimbursement. They are the CMS 450 (UB-04), which is the institutional claim form, and the CMS 1500 (08/05), which is the professional claim form.
What is the aBN? When should i use the aBN?TherevisedAdvancedBeneficiaryNotice(FormCMS–R-131)shouldbeusedbyprovidersand physicians in all situations where Medicare payment is expected to be denied.
How can i verify if the wireless capsule endoscopy will be paid by my patient’s health insurance plan?
When billing for wireless capsule endoscopy, always check with the individual payer firstforreimbursementrequirementsbeforesubmittingaclaim.YoucanalsocontactourReimbursement Helpline for assistance.
FaQ
CiTed sourCesU.S. Department of Health & Human Services, CMS/Centers for Medicare & Medicaid Services. LCD for Wireless Capsule Endoscopy (L1831); [updated 8-17-08; cited 1-7-09]. Available at: http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=1831&lcd_version=19&show=all
American Medical Association, CPT © 2007, all rights reserved. Current Procedural Terminology CPT® 2009 Professional Edition. American Medical Association, 2008.
Medicare’s National Level II Codes; Healthcare Common Procedure Coding System, HCPCS 2009. American Medical Association, 2008.
U.S. Department of Health & Human Services, CMS/Centers for Medicare & Medicaid Services. CMS 2009 Final Rules – Physician and HOPD Fee Schedules; [cited 1-7-09]. CMS 2009 Physician Fee Final Rule available at: http://edocket.access.gpo.gov/2008/E8-26213.htm
oTHer sourCesU.S. Department of Health & Human Services, CMS/Centers for Medicare & Medicaid Services. 42 CFR Parts 405, 409, et al. Medicare Program; Payment Policies Under the PhysicianFeeScheduleandOtherRevisionstoPartBforCY2009;E-PrescribingExemptionfor Computer-Generated Facsimile Transmissions; and Payment for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); Final Rule. Federal Register / Vol. 73, No. 224/ Wednesday, November 19, 2008 / Rules and Regulations; [cited 1-7-09]. CMS 2009 Physician Fee Final Rule available at: http://edocket.access.gpo.gov/2008/E8-26213.htm
U.S. Department of Health & Human Services, CMS/Centers for Medicare & Medicaid Services. Physician Fee Schedule. Relative Value Files. Details for 2009; [updated 1-5-09; cited 1-7-09]. CMS 2009 Physician Fee Schedule Relative Value Files available at: http://www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS1218948&intNumPerPage=10
U.S. Department of Health & Human Services, CMS/Centers for Medicare & Medicaid Services.FinalChangestotheHospitalOutpatientProspectivePaymentSystemandCY2009Payment Rates; [updated 1-5-09; cited 1-7-09]. CMS 2009 HOPPS Final Rule available at: http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/itemdetail.asp?itemID=CMS1213303
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